Patient Admission Form To help us provide the best care, please complete the Patient Admission form: "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.Date* Client NamePhone Number*Clinic **Clinic *RRVCTCAHPatient NameEmergency Phone NumberWhy are you presenting your pet(s) for an exam today? Please include symptoms and duration.Since you first noticed the symptoms, is your pet Better Worse Same Is your pet currently on medications? Yes No When is the last time your pet was given medications?Is your pet currently taking preventative for ticks/fleas? Yes No Is your pet currently taking preventative for heartworm? Yes No Do you keep your pet(s) Indoor Outdoor What type of food do you currently feed your pet?When is the last time your pet has eaten?Has your pet lost or gained weight recently? No Yes How Much / What PeriodHas your pet's water intake changed? No Yes How Much / What PeriodHas your pet's excretory habits changed? No Yes How Much / What PeriodTreatment Authorization I hereby authorize Kentucky Veterinary Practice Group clinics to perform medical and initial diagnostics/surgical procedures on this animal as required for diagnosis and treatment. Please be advised we are not responsible for any personal belongings left with your pet. All pets must be free of fleas. If any are seen, the pet will be safely treated at the owner's expense. In the event of a medical emergency, our veterinarians will provide necessary and resonable medical care. Please provide emergency contact information above so that we may reach you in such an event. Your pet will be seen on a priority basis. This will be based on the nature of the problem and the time your pet was dropped-off. If you are unable to pick your pet up by clinic closing time, you may be charged an additional boarding fee.Payment is due as services are rendered; the balance is due upon discharge from the clinic. Payments can be made by cash, personal check (with proper identification), Visa, Mastercard, Discover, American Express or Care Credit.CAPTCHA
